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Bhutan is one of the biological hotspots in the world where humans and natural flora and fauna co-exist in close proximity. Bhutan is home to two species of bears: Sloth Bear and Himalayan Black Bear. Human conflicts with bears are reported from all over the country. This study describes the profile of the victims and the pattern of injury resulting from bear attacks and circumstances around human conflicts with bears in Bhutan between 2015 and 2019. This was a cross-sectional study with a review of hospital records of patients treated at the National Referral Hospital from 01 January 2015 till 31 December 2019. Data were extracted into a structured pro forma and entered into EpiData Entry 3.1 and analysed in STATA 13.1. There were thirty-four patients who were provided care for bear maul injuries, with an average annual caseload of 6.8 cases per year. The injury prevalence was 100% and the kill prevalence was 0%. Bear attacks were reported from fourteen of twenty districts of the country. The mean age of the victims was 49 (±13) years. Males (26, 76%) and farmers (26, 76%) were the common victims; the risk of bear attacks was 0.16 per 100,000 farmers per year. The commonest region of the body attacked was the face (29, 85%) and victims were provided emergency and rehabilitative care within and outside the country. Thirty-three victims (97%) were provided post-exposure prophylaxis for rabies. All victims received antibiotics despite the lack of national guidelines on the choice of antibiotics post-bear maul. Human-bear conflict is multi-faceted, puts a considerable strain on bear-conservation efforts and requires multi-disciplinary efforts in the prevention of human injury and socioeconomic losses.

Antimicrobial resistance is (AMR) an emerging global public health problem. Rationale use of antibiotic can prevent the rise of antimicrobial resistance. The objective of this study was to understand the knowledge, attitude and practice on antibiotic usage and AMR among the veterinarians and para-veterinarians in Bhutan. A cross-sectional questionnaire survey among the veterinarians and para-veterinarians was conducted from June to July 2020. A score of one to the correct answers and zero for the wrong answers was allotted to each respondent answers. The total score was added and those who scored above the mean was categorized as having good knowledge and favourable attitude. A total of 219 animal health workers participated in this study. The mean knowledge score was 12.05 ±1.74 with 38.8% of the respondents having good knowledge on antibiotic use and AMR. Similarly, the mean scores for the attitude level were 8.32±1.61 with 51% them having favorable attitude towards antibiotic usage and AMR. The mean practice score was 3.83±1.06 with 77% of them having good practices on antibiotic use. The respondents who read national plan on AMR were found to have good knowledge on antibiotics and AMR (AOR: 2.39; 95% CI: 1.19-4.82). The female respondents (AOR: 2.16; 95% CI: 1.01-4.61), respondents from the eastern region (AOR: 2.53; 95% CI: 1.18-5.44), west central (AOR: 3; 95% CI: 1.30-6.92), animal health supervisors (AOR: 9.77; 95% CI: 1.98-48.29), and livestock production supervisors (AOR: 2.77; 95% CI: 1.21-6.35) have favorable attitude towards antibiotics and AMR. Our study identified that most animal health workers in Bhutan had poor knowledge on antibiotics usage and AMR. Therefore, regular awareness education on antibiotics and AMR in the form of refresher course/training must be provided to the animal health workers in the country to avoid inappropriate use of antibiotics.

Tuberculosis (TB) is a major public health problem in Bhutan despite the implementation of directly observed treatment short-course since 1997. This study aimed to assess the knowledge, attitude and practice on TB among the teacher trainees of Samtse College of Education. A cross-sectional study was conducted among the teacher trainees of Samtse College of Education. A standardized pretested questionnaire was distributed and self-administered. The participants were selected randomly using randomization. The data was entered in Epi-data 4.4.2.1 and analysed using STATA version 13. A score of 1 point for a correct answer and 0 for wrong/don't know answer was given. The knowledge, attitude and practice score were divided into good and poor based on 50% cut off. Logistic regression was used for the analysis to identify the significant covariates. A total of 420 trainees responded to the survey questionnaire. The average knowledge score on TB was 10.7 (Range = 0-21). Two hundred and forty respondents (58.6%) had low knowledge (mean score 7.8±2.5) on TB. Cough, chest pain and weight loss were correctly reported as the symptoms of TB by 306 (72.9%), 187(44.5%) and 187 (44.5%) participants. Eighty-nine-point five percent (376) of participants reported coughing as the main route of TB transmission and 85% (357) of the participants said that it could be prevented by covering the mouth while coughing. In multivariable analysis; the trainees in the junior years of college had good knowledge of TB compared with the senior years (adjusted odds ratio [AOR] 2.02; 95% confidence interval [CI] 1.18-3.5; p-value 0.011). Respondents previously treated for TB were more likely to have good knowledge on TB compared to those who never had TB in the past (AOR 2.39; 95% CI 1.07-5.31; p-value 0.033). The majority (93%) of respondents had a good attitude towards TB cases. Female trainees were 2.4 (95% CI 1.02-5.62; p-value 0.045) times more likely than male trainees to have a positive attitude towards TB. Eighty-eight percent of the respondents reported that they would visit the hospital if they had TB symptoms. The mean score for the practice on TB was 1.33±0.59 (Range:0-2). In this study, the majority of the trainees had poor knowledge on TB, especially among the trainees in senior years of college and those who had never suffered from TB. The attitude towards TB was good especially among the female trainees. However, the overall practice was poor among the participants. Therefore, the Ministry of Health should collaborate with relevant stakeholders especially the Ministry of Education to incorporate topics on TB in the syllabus of students and colleges to create awareness on it.

The unmet needs of contraception can lead to unintended pregnancy and transmission of sexually transmitted infections (STI). Therefore, this study aimed to evaluate the contraception use, knowledge, and attitude on STI among students under Royan University of Bhutan (RUB). This was a cross-sectional study using an online questionnaire. The questionnaire was developed in Google forms and the link was shared through the college WeChat groups. The questionnaire consisted of four parts on socio-demographic, sexual behaviour and contraceptive use, knowledge, and attitude on STIs. All the students under RUB were invited to participate voluntarily in this study. The socio-demography was presented in frequency and proportion. A total of 1,283 students participated in this survey and 55.0% (701) were females. Of this, 29.4% (377) were sexually active and 94.4% reported using modern contraception. Commonly used contraceptives were: condoms (83.8%, 316) and emergency contraceptives (20.6%, 78), respectively. The mean knowledge and attitude scores on STI were 9.94 (range 2-20) and 12 (range 2-14), respectively. Good knowledge and attitude on STI were reported in 53.2% (683) and 70.1% (899) of participants. Students reported average knowledge and a good attitude towards STI. Contraceptive use among university students was low. There is a need to strengthen health education on STIs in schools and universities. All forms of contraceptives especially condoms should be made easily available to sexually active people.

Modelling studies predict significant reduction in overall attack rates by SARS-CoV-2 through use of effective COVID-19 vaccines, with the highest relative reduction among older adults (aged 65 years and older), reduction of intensive care admissions and deaths.1 As of 18 April 2021, 14 vaccines have been approved for human use by at least one country2 and 890 million doses of COVID-19 vaccines have been administered globally.3 In the South Asia region, the Oxford-AstraZeneca (COVISHIELD) vaccine manufactured in India has been made available through the COVAX Facility.2 As of 18 April 2021, 122 million doses (7.9% of the population) have been administered in India, 6.6 million doses (3.5%) in Bangladesh, 0.9 million doses (4.3%) in Sri Lanka, 0.8 million doses in Pakistan, 0.3 million doses (54%) in Maldives and 0.1 million doses (0.3%) in Afghanistan.3 Bhutan, a country with a population of 0.72 million, has vaccinated 472 139 individuals with the first dose of COVISHIELD covering 94% of the eligible population (18 years and older) within a span of 2 week.4 Bhutan has reported a total of 957 cases of COVID-19 up till 18 April 2021 with one death.4 The country has seen two nationwide lockdowns and disruption of public services, schools and colleges.5 6 The physical distancing measures and the closure of international borders has impacted almost all sectors of socioeconomic activities in the country with the major brunt on the tourism, entertainment and export–import industries leading to an all-time high unemployment rate. Identification of vaccination centres were key in the placement of cold chain storages at central locations catering to several vaccination centres in the catchment area. In the months leading up to the vaccine roll out, multiple batches of health workers were trained on the management and monitoring of vaccine cold chain, organisation of vaccination booths, delivery of vaccine and post-vaccination monitoring. The vaccines were delivered to regional and district cold storage centres from where daily doses of vaccines were released on the days of vaccination.

Physiotherapy and rehabilitative services are an integral part of patient care, but in many developing countries they are not considered a priority and are either not available or not easily accessible to those who need them. Bhutan is one such country where healthcare is provided free of cost to all, but as of 2021 physiotherapy services were available only in 26 of 48 hospitals and 19 of 20 districts. The number of physiotherapy professionals per 10,000 population is 1.4 with significant rates of attrition. There is lack of awareness among patients and other health professionals about physiotherapy and rehabilitation services. The country needs to integrate physiotherapy and rehabilitation services into the overall health policy framework and develop proper planning of human resources and infrastructure to meet the current and future demands.

The classification of snakebite is based on clinical examination and laboratory tests. In cases, of suspected hemotoxic snakebite, the anti‐snakebite venom (ASV) is administered based on 20‐minute whole blood clotting time. However, the use of ASV should be guided by the presence of bleeding diathesis along with raised clotting time. The classification of snakebite is based on clinical examination and laboratory tests. In cases, of suspected hemotoxic snakebite, the anti‐snakebite venom (ASV) is administered based on 20‐minute whole blood clotting time. However, the use of ASV should be guided by the presence of bleeding diathesis along with raised clotting time.

Background and Aims Bhutan first introduced the Shorter Regimen, consisting of a combination of Amikacin, Clofazamine, Ethionamide, Ethambutol, high dose Isoniazid, Moxifloxacin and Pyrazinamide, for the treatment of rifampicin or multidrug resistant tuberculosis (RR/MDR‐TB) in 2018. This study describes the outcome, time to sputum conversion and adverse events of treatment among MDR‐TB patients treated with the Shorter Regimen in Bhutan. Methods This was a longitudinal study among patients with RR/MDR‐TB who were treated with the Shorten Regimen between 2018 and 2020. Throughout the treatment period, sputum smear, culture, and blood investigations were monitored. Results There were 52 patients who received the shorter regimen for MDR‐TB. Forty‐seven patients (90%) had pulmonary TB (PTB) and five (10%) had extra‐pulmonary TB (EPTB). Forty‐one patients (79%) had confirmed MDR‐TB and 11 (21%) had RR‐TB. MDR‐TB was detected in new cases in 35 patients (69%), while 11 (22%) were cases of TB relapse and five (10%) were cases of treatment failure. There were 40 patients (86%) who achieved sputum smear conversion by the end of 4 months while all patients became culture negative by the end of 3 months. All patients achieved culture conversion by the end of 3 months. The treatment success rate was 94% and there were no deaths. The common side effects were nausea, vomiting, arthralgia, dizziness, sleep disturbances, depressed mood and skin rash. QTc prolongations were observed in six patients, for which five patients needed dose modification of Moxifloxacin. Five patients had hepatitis, and two needed dose modification. Two patients were switched to the longer regimen due to amikacin‐induced profound hearing loss and nephrotoxicity. Conclusions The treatment success rate of MDR‐TB was high, with high sputum and culture conversion rates. Adequate monitoring of side effects is important in providing timely intervention.

Objective To study the profile, clinical presentation and outcome of hospital stay among patients admitted with warfarin toxicity at the Jigme Dorji Wangchuck National Referral Hospital, Bhutan. This was a cross-sectional study with a review of hospital records of patients admitted between 01 and 2018 and 30 June 2020. Results There were 22 admissions due to warfarin toxicity. The mean age of patients was 55.9 (± SD 20.2) years, the median duration of warfarin therapy was 30 months (IQR 4.8, 69 months). The indications for warfarin were atrial fibrillation (9, 40.9%), mechanical heart valves (6, 27.3%), deep vein thrombosis (6, 27.3%) and pulmonary thromboembolism (1, 4.5%). The mean of dosage of warfarin was 4.3 (± 2.6) mg and the cumulative dosage in the week prior to admission was 30.9 (± 18.6) mg. The mean of INR at presentation was 7.7 (± 4.3) with the maximum noted at 20. The patients presented with gastrointestinal bleeding, muscle haematomas, epistaxis and oral cavity bleeding. There was no mortality related to warfarin toxicity. The reasons for warfarin toxicity included patient dosing error and drug interactions. Warfarin therapy requires appropriate patient education, adequate facilities for follow-up and avoidance of warfarin wherever possible in clinical settings.

Background The third Sustainable Development Goal for 2030 development agenda aims to reduce maternal and newborn deaths. Pregnant women’s understanding of danger signs is an important factor in seeking timely care during emergencies. We assessed knowledge of obstetric danger signs using both recall and understanding of appropriate action required during obstetric emergencies. Methods This was a cross-sectional study among pregnant women attending antenatal clinic at Bhutan’s largest hospital in Thimphu. Recall was assessed against seven obstetric danger signs outlined in the Mother and Child Health Handbook (7 points). Understanding of danger signs was tested using 13 multiple choice questions (13 points). Knowledge was scored out of 20 points and reported as ‘good’ (≥80%), ‘satisfactory’ (60–79%) and ‘poor’ (< 60%). Correlation between participant characteristics and knowledge score as well as number of danger signs recalled was tested using Pearson’s correlation coefficient. Association between knowledge score and participant characteristics was tested using t-tests (and Kruskal-Wallis test) for numeric variables. Socio-demographic and clinical characteristics associated with the level of knowledge ('good’ versus ‘satisfactory’ and ‘poor’ combined) were assessed with odds ratios using a log-binomial regression model. All results with p  < 0.05 were considered significant. Results Four hundred and twenty-two women responded to the survey (response rate = 96.0%). Mean (±SD) knowledge score was 12 (±2.5). Twenty women (4.7%) had ‘good’ knowledge, 245 (58.1%) had ‘satisfactory’ knowledge and 157 (37.2%) had ‘poor’ knowledge. The median number of danger signs recalled was 2 (IQR 1, 3) while 68 women (20.3%) could not recall any danger signs. Most women were knowledgeable about pre-labour rupture of membranes (96.0%) while very few women were knowledgeable about spotting during pregnancy (19.9%). Both knowledge score and number of danger signs recalled had significant correlation with the period of gestation. Women with previous surgery on the reproductive tract had higher odds of having ‘good’ level of knowledge. Conclusions Most pregnant women had ‘satisfactory’ knowledge score with poor explicit recall of danger signs. However, women recognized obstetric emergencies and identified the appropriate action warranted.